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APPLICATION FOR PERMIT l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> t Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I, (Complete in Triplicate) <br /> lor <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andInst work herein described. This application is <br /> made in compliance with San Joaquin Cou'n'ty Ordinance No.549 for sewage or No. 1862 for well/ <br /> andd the"i�utes and Regulations of the San Joaquin <br /> the <br /> Local Health District. <br /> I 1 G '(, 1✓ {, 1�n Lot Size PM <br /> City <br /> Job Address 1 <br /> Phone <br /> Owner's Name )c 0 r f Address <br /> A.c.f T� Address b r�0 �� License No Phone - <br /> Contractor `� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1:1DESTRUCTION Ll <br /> OTHER ❑ <br /> PUMP INSTALLATION ❑ `',; SYSTEM REPAIR.❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED:USE-. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> LJIndustrial�` F] Open Bottom 15 Manteca Dia. of Well Excavation Specifications <br /> Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> I'] Public <br /> f-! Other ❑ Delta Depth of Grout Seal Type of Grout — <br /> _ <br /> I I Irrigation _._Approx.'I]epth t.1 Eastern H P State Work Done <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump# <br /> Well Destruction ❑ Well DiameterSealing Material (top 501 <br /> Depth Filler Material IBelo 60') y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I i aNailabPe1within 200 feetc system .)' if public sewer is <br /> Installation will serve: ResidencerCommercial_ Oiher`� - <br /> Number of living units: Number of bedrooms <br /> of v Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity . No. Compartments <br /> I PKG. TREATMENT PLT'.❑— '�� , <br /> Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> c� l� <br /> y c + 1) Total length/size <br /> l LEACHING LINE No. & Length of lines / t <br /> fi f Property.Line <br /> FILTER BED ❑ Distance'. nearest: <br /> We Foundation <br /> SEEPAGE PITS FI Depth I Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS, .. ❑. ��. <br />`r that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> -k", <br /> I hereby certify that I have prepared this application and <br /> rules and regulations of the San Joaquin Local Health Dihtrict. <br /> signature y that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's certifies the following:`I certif <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all r uir d inspections. Complete drawing on r§verse side. <br /> Title: Date: <br /> Signed X <br /> FOR EPARTMENT USE ONLY <br /> 1 Date rea <br /> Application Accepted by' <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant.:;Return all copies tri: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> "FEES — Lj OVNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE ;Z37 <br /> "VO. <br /> INFO <br /> 0 ,� <br /> EH 14-26 - <br />